Cost savings associated with filling a 3-month supply of prescription medicines

Barriers to Adherence with Immunosuppressive Therapy in Patients with Uveitis

PURPOSE

To evaluate the barriers to adherence with immunomodulatory therapy (IMT) for patients with uveitis across multiple regions of the United States.

METHODS

A multi-center survey of adult and pediatric patients with ocular inflammatory diseases undergoing treatment with IMT was conducted between September 2021 and August 2022. Participating sites included Johns Hopkins Wilmer Eye Institute, Wong Eye Institute of the University of Texas at Austin, University of Wisconsin-Madison, University of Minnesota, Veterans Affairs Hospital of Minneapolis, and Washington University of St. Louis. Each patient completed a self-reporting survey to identify barriers to adherence.

RESULTS

The survey was completed by 98 subjects, of whom were 71% white, 67% female, and 61% had a college or advanced degree. Nearly half (49%) were on two or more IMTs of which the most common were methotrexate (38%), mycophenolate (36%), or adalimumab (36%). Nearly half (52%) of patients required reminders to take their medications and 20% found it difficult to take IMT regularly, with 12% struggling to take medications multiple times a day. A lack of refills resulted in 15% of patients missing doses. Limitations to completing laboratory studies to monitor for drug-related side-effects included finding time (10%) and cost (22%).

CONCLUSION

Barriers to IMT treatment include laboratory study cost, difficulty with medication administration, and adhering to medication schedules. Monthly cost of medication was high for some, but no patients were unable to take IMT due to insurance loss. Addressing these barriers may improve IMT adherence for uveitis patients and better clinical outcomes.

Barriers to Adherence with Clinic Visits in Patients with Uveitis

PURPOSE

To assess the patient barriers to adherence with appointment follow-up in patients with ocular inflammatory disorders across the United States.

METHODS

This was a multicenter study of adult and pediatric patients at the Wilmer Eye Institute, University of Texas at Austin, University of Wisconsin-Madison, University of Minnesota, Minneapolis Veterans Administration Hospital, and Washington University of St. Louis. The primary outcome was self-reported adherence to follow-up visits. Secondary outcomes were the reasons for missing follow-up including sub analyses of patient demographics. Eligible patients completed a self-reporting survey to assess barriers to attending follow-up visits.

RESULTS

The survey was fully completed by 210 subjects and partially by 40 (250 in total), of whom were 67% white, 59% female, and 51% had a college or advanced degree. Most patients had bilateral (68%), anterior (51%) uveitis. Patients were treated with topical corticosteroids (33%), immunosuppressive agents (23%), or both (22%). Most patients (79%) did not miss or cancel appointments. Ninety-seven percent of patients had medical insurance and some paid (39%) more than 40 dollars for their copay. Copay costs limited the number of visits patients could attend in 7% of patients. Eight percent of patients missed appointments due to inability to take off time from work and 5% missed visits due to lack of transportation.

CONCLUSION

Most patients with ocular inflammation reported good adherence to follow-up appointments. Insurance type, copay costs, transportation, patient scheduling, and patient understanding were all minimally reported to effect patient visit attendance.

The impact of long-term prescription policy on primary care utilisation and costs among hypertensive patients in China: a six-year longitudinal study

Background

China has recently implemented a long-term prescription policy as a component of the family doctor system in order to strengthen chronic disease management. In this study, we evaluated the net policy impact on health care utilisation and costs at community health centres (CHCs) among hypertensive patients.

Methods

The study population included 164 857 hypertensive patients from a provincial capital city in Eastern China, with an average age of 69.93 years in 2014. We collected their health care utilisation and costs from 1 January 2014 to 31 December 2019 from the medical insurance claims database. The long-term prescription policy, implemented in 2018, allows patients registered with family doctors to obtain up to three-month prescriptions. We applied the multi-stage difference-in-differences model to examine the policy's impact, comparing health care utilisation and costs between those eligible and for the long-term prescription policy and those who are not.

Results

The long-term prescription policy significantly reduced hypertensive patients' annual outpatient visits by 2.47 at CHCs and 0.18 at pharmacies, as well as prolonged the interval of prescriptions by 3.10 days at CHCs. It decreased the annual drug costs at pharmacies by 47%, but there was no significant effect on the annual outpatient costs at CHCs. Meanwhile, we did not observe the impact of the long-term prescription policy on patients' annual number of hospitalisations.

Conclusions

The long-term prescription policy mainly affected patients' health care utilisation at CHCs and did facilitate patients with chronic diseases to refill drugs conveniently. The policy impact on patient health outcomes needs to be further observed and more attention should be given to the factors that may influence family doctors' behaviour in delivering the long-term prescription service.

Financial Implications of 12-Month Dispensing of Oral Contraceptive Pills in the Veterans Affairs Health Care System

IMPORTANCE

The Veterans Affairs (VA) health care system is the largest integrated health care system in the United States. Like most US health plans, the VA currently stipulates a 3-month maximum dispensing limit for all medications, including oral contraceptive pills (OCPs). However, 12-month OCP dispensing has been shown to improve continuation of use, decrease coverage gaps, and reduce unintended pregnancy in other practice settings.

OBJECTIVE

To estimate the financial and reproductive health implications for the VA of implementing a 12-month OCP dispensing option, with the goal of informing policy change.

DESIGN, SETTING, AND PARTICIPANTS

A decision model from the VA payer perspective was developed to estimate incremental costs to the health care system of allowing the option to receive a 12-month supply of OCPs up front, compared with the standard 3-month maximum, during a 1-year time horizon. A model cohort of 24 309 reproductive-aged, heterosexually active, female VA enrollees who wish to avoid pregnancy for at least 1 year was assumed. Probabilities of continuation of OCP use, coverage gaps, pregnancy, and pregnancy outcomes were drawn from published data. Costs of OCP provision and pregnancy-related care and the number of women using OCPs were drawn from VA administrative data. One-way and probabilistic sensitivity analyses were performed to assess model robustness.

MAIN OUTCOMES AND MEASURES

Incremental per-woman and total costs to the VA of allowing for 12-month dispensing of OCPs compared with standard 3-month dispensing.

RESULTS

The 12-month OCP dispensing option, modeled from the VA health system perspective using a cohort of 24 309 women, resulted in anticipated VA annual cost savings of $87.12 per woman compared with the cost of 3-month dispensing, or an estimated total savings of $2 117 800 annually. Cost savings resulted from an absolute reduction of 24 unintended pregnancies per 1000 women per year with 12-month dispensing, or 583 unintended pregnancies averted annually. Expected cost savings with 12-month dispensing were sensitive to changes in the probability of OCP coverage gaps with 3-month dispensing, the probability of pregnancy during coverage gaps, and the proportion of pregnancies paid for by the VA. When simultaneously varying all variables across plausible ranges, the 12-month strategy was cost saving in 95.4% of model iterations.

CONCLUSIONS AND RELEVANCE

Adoption of a 12-month OCP dispensing option is expected to produce substantial cost savings for the VA while better supporting reproductive autonomy and reducing unintended pregnancy among women veterans.

Addressing Medication Costs During Primary Care Visits: A Before-After Study of Team-Based Training

BACKGROUND

Medications contribute to patients' out-of-pocket costs, yet most clinicians do not routinely screen for patients' cost-of-medication (COM) concerns.

OBJECTIVE

To assess whether a single training session improves COM conversations.

DESIGN

Before-after cross-sectional surveys of patients and qualitative interviews with clinicians and staff.

SETTING

7 primary care practices in 3 U.S. states.

PARTICIPANTS

In total, 700 patients were surveyed from May 2017 to January 2018: 50 patients per practice before the intervention and another 50 patients per practice after the intervention. Eligibility criteria included age 18 years or older and taking 1 or more long-term medications. Qualitative interviews with 45 staff members were conducted.

INTERVENTION

A single 60-minute training session for clinicians and staff from each practice on COM importance, team-based screening, and cost-saving strategies.

MEASUREMENTS

Patient data (demographics, number of long-term medications, total monthly out-of-pocket medication costs, and history of cost-related medication nonadherence) were obtained immediately before and 3 months after the intervention. Practice staff were interviewed 3 months after the intervention.

RESULTS

A total of 700 patient surveys were completed. Frequency of COM discussion improved in 6 of the 7 practices and remained unchanged in 1 practice. Overall, COM conversations with patients increased from 17% at baseline to 32% postintervention (P = 0.00). There was substantial heterogeneity among sites in before-after differences in patient-reported out-of-pocket COM. Qualitative analyses from key informant interviews showed wide variation in implementation of screening approaches, workflow, adoption of a team-based approach, and strategies for addressing COM.

LIMITATION

It is not known whether improvements in COM conversations were sustained beyond 3 months.

CONCLUSION

A single team training to screen and address patients' medication cost concerns improved COM discussions over the short term. Further research is needed to assess sustained effects and impact on patient costs and medication adherence and to determine whether more intensive, scalable interventions are needed.

PRIMARY FUNDING SOURCE

Robert Wood Johnson Foundation.

Impact of issuing longer- versus shorter-duration prescriptions: a systematic review

BACKGROUND

Long-term conditions place a substantial burden on primary care services, with drug therapy being a core aspect of clinical management. However, the ideal frequency for issuing repeat prescriptions for these medications is unknown.

AIM

To examine the impact of longer-duration (2-4 months) versus shorter-duration (28-day) prescriptions.

DESIGN AND SETTING

Systematic review of primary care studies.

METHOD

Scientific and grey literature databases were searched from inception until 21 October 2015. Eligible studies were randomised controlled trials and observational studies that examined longer prescriptions (2-4 months) compared with shorter prescriptions (28 days) in patients with stable, chronic conditions being treated in primary care. Outcomes of interest were: health outcomes, adverse events, medication adherence, medication wastage, professional administration time, pharmacists' time and/or costs, patient experience, and patient out-of-pocket costs.

RESULTS

From a search total of 24 876 records across all databases, 13 studies were eligible for review. Evidence of moderate quality from nine studies suggested that longer prescriptions are associated with increased medication adherence. Evidence from six studies suggested that longer prescriptions may increase medication waste, but results were not always statistically significant and were of very low quality. No eligible studies were identified that measured any of the other outcomes of interest, including health outcomes and adverse events.

CONCLUSION

There is insufficient evidence relating to the overall impact of differing prescription lengths on clinical and health service outcomes, although studies do suggest medication adherence may improve with longer prescriptions. UK recommendations to provide shorter prescriptions are not substantiated by the current evidence base.

Retrospective, multicohort analysis of the Clinical Practice Research Datalink (CPRD) to determine differences in the cost of medication wastage, dispensing fees and prescriber time of issuing either short (<60 days) or long (≥60 days) prescription lengths in primary care for common, chronic conditions in the UK

OBJECTIVES

To investigate patterns of early repeat prescriptions and treatment switching over an 11-year period to estimate differences in the cost of medication wastage, dispensing fees and prescriber time for short (<60 days) and long (≥60 days) prescription lengths from the perspective of the National Health Service in the UK.

SETTING

Retrospective, multiple cohort study of primary care prescriptions from the Clinical Practice Research Datalink.

PARTICIPANTS

Five random samples of 50 000 patients each prescribed oral drugs for (1) glucose control in type 2 diabetes mellitus (T2DM); (2) hypertension in T2DM; (3) statins (lipid management) in T2DM; (4) secondary prevention of myocardial infarction; and (5) depression.

PRIMARY AND SECONDARY OUTCOME MEASURES

The volume of medication wastage from early repeat prescriptions and three other types of treatment switches was quantified and costed. Dispensing fees and prescriber time were also determined. Total unnecessary costs (TUC; cost of medication wastage, dispensing fees and prescriber time) associated with <60 day and ≥60 day prescriptions, standardised to a 120-day period, were then compared.

RESULTS

Longer prescription lengths were associated with more medication waste per prescription. However, when including dispensing fees and prescriber time, longer prescription lengths resulted in lower TUC. This finding was consistent across all five cohorts. Savings ranged from £8.38 to £12.06 per prescription per 120 days if a single long prescription was issued instead of multiple short prescriptions. Prescriber time costs accounted for the largest component of TUC.

CONCLUSIONS

Shorter prescription lengths could potentially reduce medication wastage, but they may also increase dispensing fees and/or the time burden of issuing prescriptions.